nevada medicaid and nevada checkup ncpdp d.0 payer sheet ... · 1Ø1-a1 bin number 001553 m 1Ø2-a2...

1

Document version: 3.0 Document ID: 7.0

Nevada Medicaid and Nevada Checkup

NCPDP D.0 Payer Sheet for Pharmacy Providers Effective January 1, 2012

NCPDP Version D Claim Billing/Claim Rebill

GENERAL INFORMATION

Payer Name: SXC Health Solutions Date: 11/6/2011

Plan Name/Group Name: Nevada Medicaid/Nevada

Checkup

BIN: 001553 PCN: NVM

Processor: SXC Health Solutions

Effective as of: 1/1/2012 NCPDP Telecommunication Standard Version/Release #:

D.O

NCPDP Data Dictionary Version Date: August 2011 NCPDP External Code List Version Date: August 2011

Contact/Information Source: SXC Health Solutions, Inc. PO Box 5206, Lisle, IL 60532-5206, 866-244-8554

Certification Testing Window: November 1 – November 30, 2011

Certification Contact Information: send email to: [email protected]

Provider Relations Help Desk Info: 866-244-8554

Other versions supported: None

Changes to updated payer sheet version – 3.0 11/06/2011

Page # Description

1 Effective date for D.0 is changed to 01/01/2012

1 NCPDP Telecommunication Standard Version/Release #: D.0 – changed from 5.1

2 Field 102-A3 – B2 transaction is now included in a separate segment listing below

2 Field 102-A2 – updated from 5.1 to D.0

2 Deleted duplicate tables and text – GENERAL INFORMATION, Field legend for columns, CLAIM

BILLING/CLAIM REBILL TRANSACTION

3 Field 384-4X – New field for D.0 – changed from Patient Location, added 02=skilled nursing facility

and 03=nursing facility to better capture data

11 Field 337-4C – Increased maximum count from 3 to 9

11-13 Fields 353-NR, 351-NP, and 352-NQ added

Field legend for columns

Payer usage column Value Explanation Payer

situation

column

MANDATORY M The Field is mandatory for the Segment in the designated

Transaction.

No

Required R The Field has been designated with the situation of

"Required" for the Segment in the designated Transaction.

No

Qualified Requirement RW ―Required when‖. The situations designated have

qualifications for usage ("Required if x", "Not required if y").

Yes

Fields that are not used in the Claim Billing/Claim Rebill transactions and those that do not have qualified

requirements (that is, not used) for this payer are excluded from the template.

NCPDP D.0 Payer Sheet for Pharmacy Providers

2


CLAIM BILLING/CLAIM REBILL TRANSACTION

The following lists the segments and fields in a Claim Billing or Claim Rebill Transaction for the NCPDP

Telecommunication Standard Implementation Guide Version D.Ø.

Transaction header segment questions Check Claim billing/Claim rebill

If situational, payer situation

This Segment is always sent X

Source of certification IDs required in Software

Vendor/Certification ID (11Ø-AK) is Payer Issued


Vendor/Certification ID (11Ø-AK) is Switch/VAN

issued


Vendor/Certification ID (11Ø-AK) is Not used

Transaction header segment Claim billing/Claim rebill

Field # NCPDP field name Value Payer

usage

Payer situation

1Ø1-A1 Bin number 001553 M

1Ø2-A2 Version/release number DØ M

1Ø3-A3 Transaction code B1, B3 M

1Ø4-A4 Processor control number NVM M

1Ø9-A9 Transaction count Up to 4 M

2Ø2-B2 Service provider ID qualifier 01 (NPI) M

2Ø1-B1 Service provider ID National Provider

Identifier

M

4Ø1-D1 Date of service CCYYMMDD M

11Ø-AK Software vendor/certification ID Use value for Switch’s

requirements. If

submitting claim without

a Switch, populate with

blanks.

M

Insurance Segment Questions Check Claim Billing/Claim Rebill

If Situational, Payer Situation


Insurance Segment

Segment Identification (111-AM)

= ―Ø4‖

Claim Billing/Claim Rebill

Field # NCPDP Field Name Value Payer

Usage

Payer Situation

3Ø2-C2 CARDHOLDER ID Medicaid ID Number

(Client)

M


3


Insurance Segment


= ―Ø4‖



Usage

Payer Situation

312-CC CARDHOLDER FIRST NAME R Imp Guide: Required if

necessary for

state/federal/regulatory

agency programs when the

cardholder has a first name.

Payer Requirement: Same as

Imp Guide

313-CD CARDHOLDER LAST NAME R Imp Guide: Required if

necessary for


agency programs.


Imp Guide

Patient Segment Questions Check Claim Billing/Claim Rebill



This Segment is situational

Patient Segment


= ―Ø1‖


Field NCPDP Field Name Value Payer

Usage

Payer Situation

3Ø4-C4 DATE OF BIRTH R

3Ø5-C5 PATIENT GENDER CODE R

31Ø-CA PATIENT FIRST NAME R Imp Guide: Required when the

patient has a first name.


Imp Guide

311-CB PATIENT LAST NAME R

384-4X PATIENT RESIDENCE 02 = Skilled Nursing

Facility

03 = Nursing Facility

04 = Assisted Living

Facility

11 = Hospice

RW Imp Guide: Required if this field

could result in different

coverage, pricing, or patient

financial responsibility.

Payer Requirement: Required

when needed to identify Long

Term Care (LTC) conditions


4


Claim Segment Questions Check Claim Billing/Claim Rebill



This payer supports partial fills X

This payer does not support partial fills

Claim Segment


= ―Ø7‖



Usage

Payer Situation

455-EM PREscription/Service Reference

Number Qualifier

1 = Rx Billing M Imp Guide: For Transaction

Code of B1, in the Claim

Segment, the

Prescription/Service

Reference Number Qualifier

(455-EM) is 1 (Rx Billing).

4Ø2-D2 Prescription/Service Reference

Number

M

436-E1 Product/Service ID Qualifier 03 = NDC M

4Ø7-D7 Product/Service ID 11-digit NDC M

456-EN ASSOCIATED

PRESCRIPTION/SERVICE

REFERENCE NUMBER

RW Imp Guide: Required if the

completion transaction in a

partial fill (Dispensing Status

(343-HD) = C (Completed)).

Required if the Dispensing

Status (343-HD) = P (Partial

Fill) and there are multiple

occurrences of partial fills for

this prescription.


Imp Guide

457-EP ASSOCIATED

PRESCRIPTION/SERVICE DATE


completion transaction in a

partial fill (Dispensing Status

(343-HD) = C (Completed)).

Required if Associated

Prescription/Service Reference

Number (456-EN) is used.

Required if the Dispensing

Status (343-HD) = P (Partial

Fill) and there are multiple

occurrences of partial fills for

this prescription.


5


Claim Segment


= ―Ø7‖



Usage

Payer Situation


Imp Guide

442-E7 QUANTITY DISPENSED R

4Ø3-D3 FILL NUMBER 0 = Original dispensing

199 = Refill Number

R

4Ø5-D5 DAYS SUPPLY R

4Ø6-D6 COMPOUND CODE 0 = Not Specified

1 = Not a Compound

2 = Compound

R

4Ø8-D8 DISPENSE AS WRITTEN

(DAW)/PRODUCT SELECTION

CODE

0 = No Product selection

indicated

1 = Substitution not

allowed by prescriber

2 = Substitution allowed –

patient requested brand


pharmacist selected

product dispensed


generic drug not in stock


brand drug dispensed as

generic

6 = Override

7 = Substitution not

allowed – brand drug

mandated by law


generic drug not available

in marketplace

9 = Other

R

414-DE DATE PRESCRIPTION WRITTEN R

354-NX SUBMISSION CLARIFICATION

CODE COUNT

Maximum count of 3. RW Imp Guide: Required if

Submission Clarification Code

(42Ø-DK) is used.


Imp Guide

42Ø-DK SUBMISSION CLARIFICATION

CODE

RW Imp Guide: Required if

clarification is needed and

value submitted is greater than

zero (Ø).

If the Date of Service (4Ø1-D1)


6


Claim Segment


= ―Ø7‖



Usage

Payer Situation

contains the subsequent payer

coverage date, the Submission

Clarification Code (42Ø-DK) is

required with value of 19

(Split Billing – indicates the

quantity dispensed is the

remainder billed to a

subsequent payer when

Medicare Part A expires. Used

only in long-term care settings)

for individual unit of use

medications.


Imp Guide

3Ø8-C8 OTHER COVERAGE CODE 00 = Not specified

01 = No other coverage

02 = Other coverage

exists – payment collected

03 = Other coverage

exists – claim not covered

04 = Other coverage

exists – payment not

collected

05 = Managed care plan

denial

06 = Other coverage

denied – not a

participating provider

07 = Other coverage

exists – Not in effect on

DOS

08 = Claim is billing for

copay

RW Imp Guide: Required if needed

by receiver, to communicate a

summation of other coverage

information that has been

collected from other payers.

Required for Coordination of

Benefits.


Imp Guide

429-DT SPECIAL PACKAGING INDICATOR 3 = Pharmacy Unit Dose RW Imp Guide: Required if this

field could result in different




when the pharmacy has

repackaged a non-unit dose

product


7


Claim Segment


= ―Ø7‖



Usage

Payer Situation

453-EJ ORIGINALLY PRESCRIBED

PRODUCT/SERVICE ID QUALIFIER


Originally Prescribed

Product/Service Code (455-

EA) is used.


Imp Guide

445-EA ORIGINALLY PRESCRIBED

PRODUCT/SERVICE CODE


receiver requests association to

a therapeutic, or a preferred

product substitution, or when a

DUR alert has been resolved

by changing medications, or

an alternative service than

what was originally

prescribed.


Imp Guide

446-EB ORIGINALLY PRESCRIBED

QUANTITY


receiver requests reporting for

quantity changes due to a

therapeutic substitution that

has occurred or a preferred

product/service substitution

that has occurred, or when a

DUR alert has been resolved

by changing quantities.


Imp Guide

6ØØ-28 UNIT OF MEASURE EA = Each

GM = Grams

ML = Milliliters


necessary for


agency programs.

Required if this field could

result in different coverage,

pricing, or patient financial

responsibility.


Imp Guide


8


Claim Segment


= ―Ø7‖



Usage

Payer Situation

418-DI LEVEL OF SERVICE 3 = Emergency RW Imp Guide: Required if this





to identify emergency

conditions

461-EU PRIOR AUTHORIZATION TYPE

CODE

RW Imp Guide: Required if this





Imp Guide

462-EV PRIOR AUTHORIZATION NUMBER

SUBMITTED






Imp Guide

343-HD DISPENSING STATUS RW Imp Guide: Required for the

partial fill or the completion fill

of a prescription.


Imp Guide

344-HF QUANTITY INTENDED TO BE

DISPENSED

RW Imp Guide: Required for the


of a prescription.


Imp Guide

345-HG DAYS SUPPLY INTENDED TO BE

DISPENSED

RW Imp Guide: Required for the


of a prescription.


Imp Guide

357-NV DELAY REASON CODE RW Imp Guide: Required when

needed to specify the reason

that submission of

the transaction has been

delayed.


9


Claim Segment


= ―Ø7‖



Usage

Payer Situation


Imp Guide

Pricing Segment Questions Check Claim Billing/Claim Rebill



Pricing Segment


= ―11‖



Usage

Payer Situation

4Ø9-D9 INGREDIENT COST SUBMITTED R

412-DC DISPENSING FEE SUBMITTED R Imp Guide: Required if its

value has an effect on the

Gross Amount Due (43Ø-DU)

calculation.


Imp Guide

433-DX PATIENT PAID AMOUNT

SUBMITTED

R Imp Guide: Required if this





Imp Guide

438-E3 INCENTIVE AMOUNT SUBMITTED R Imp Guide: Required if its

value has an effect on the

Gross Amount Due (43Ø-DU)

calculation.


when billing for unit dose

packaging fee

426-DQ USUAL AND CUSTOMARY

CHARGE

For Public Health Service

entities, usual and

customary charge is the

actual acquisition cost

R Imp Guide: Required if needed

per trading partner agreement.


Imp Guide

43Ø-DU GROSS AMOUNT DUE R


10


Pharmacy Provider Segment Questions Check Claim Billing/Claim Rebill


This Segment is always sent

This Segment is situational X

Prescriber Segment Questions Check Claim Billing/Claim Rebill




Prescriber Segment


= ―Ø3‖



Usage

Payer Situation

466-EZ PRESCRIBER ID QUALIFIER 01 = National Provider

Identification

R Imp Guide: Required if

Prescriber ID (411-DB) is used.


Imp Guide

411-DB PRESCRIBER ID NPI R Imp Guide: Required if this


coverage or patient financial

responsibility.

Required if necessary for


agency programs.


Imp Guide

Coordination of Benefits/Other Payments

Segment Questions

Check Claim Billing/Claim Rebill



This Segment is situational Required only for secondary, tertiary, etc claims.

Scenario 1 - Other Payer Amount Paid

Repetitions Only

Scenario 2 - Other Payer-Patient Responsibility

Amount Repetitions and Benefit Stage

Repetitions Only

Scenario 3 - Other Payer Amount Paid, Other

Payer-Patient Responsibility Amount, and

Benefit Stage Repetitions Present (Government

Programs)

X

If the payer supports the coordination of benefits/other payments segment, only one scenario method shown above

may be supported per template. The template shows the coordination of benefits/other payments segment that must

be used for each scenario method. The payer must choose the appropriate scenario method with the segment chart,


11


and delete the other scenario methods with their segment charts. See section Coordination of Benefits (COB)

Processing for more information.

Coordination of Benefits/Other

Payments Segment


= ―Ø5‖


Scenario 3 - Other Payer

Amount Paid, Other Payer-

Patient Responsibility

Amount, and Benefit Stage

Repetitions Present

(Government Programs)


Usage

Payer Situation

337-4C Coordination of Benefits/Other

Payments Count

Maximum count of 9. M

338-5C Other Payer Coverage Type 01 = Primary

02 = Secondary

03 = Tertiary

99 = Composite

M

339-6C OTHER PAYER ID QUALIFIER Required Blank = Not

Specified

01 = National Payer ID

02 = Health Industry

Number (HIN)

03 = Bank Information

Number (BIN)

04 = National

Association of Insurance

Commissioners (NAIC)

09 = Coupon

99 = Other

RW Imp Guide: Required if Other

Payer ID (34Ø-7C) is used.


Imp Guide

34Ø-7C OTHER PAYER ID Other Payer ID must =

88888


identification of the Other

Payer is necessary for

claim/encounter adjudication.


Imp Guide

443-E8 OTHER PAYER DATE CCYYMMDD RW Imp Guide: Required if

identification of the Other

Payer Date is necessary for

claim/encounter adjudication.


Imp Guide

353-NR OTHER PAYER-PATIENT

RESPONSIBILITY AMOUNT

COUNT

Maximum count of 25.


Payer-Patient Responsibility

Amount Qualifier (351-NP) is

used.


12



Payments Segment


= ―Ø5‖






Repetitions Present



Usage

Payer Situation


Imp Guide

351-NP OTHER PAYER-PATIENT


QUALIFIER

Blank = Not Specified

01 = Amt Charged

Periodic Deductible

02 = $ Charged Product

Selection/Brand Drug

03 = Amt Attrib to Sales

Tax

04 = Amt Over Periodic

Benefit Max

05 = Amount of Copay

06 = Patient Pay Amount

07 = Amount of

Coinsurance

08 = $ Charged Prod

Sel/NP form

09 = $ Charged Health

Plan Asst Amt

10 =$ Charged Prov

Network Sel

11 = $ Charged Pro

Sel/Brd NP Form

12 = $ Charged to

Coverage Gap

13 = $ Charged to

Processor Fee



Amount (352-NQ) is used.

Payer Requirement: Submit 06

for Patient Pay Amount

352-NQ OTHER PAYER-PATIENT



necessary for patient financial

responsibility only billing.



agency programs.

Not used for non-governmental

agency programs if Other

Payer Amount Paid (431-DV) is

submitted.


13



Payments Segment


= ―Ø5‖






Repetitions Present



Usage

Payer Situation

Payer Requirement: Required if

Other Coverage Code is 2, 3

or 4; Do Not Leave Blank

341-HB OTHER PAYER AMOUNT PAID

COUNT

Maximum count of 9. RW Imp Guide: Required if Other

Payer Amount Paid Qualifier

(342-HC) is used.


Imp Guide

342-HC OTHER PAYER AMOUNT PAID

QUALIFIER

Blank = Not Specified

01 = Delivery

02 = Shipping

03 = Postage

04 = Administrative

05 = Incentive

06 = Cognitive Service

07 = Drug Benefit

08 = Sum of all

reimbursement

98 = Coupon

99 = Other


Payer Amount Paid (431-DV) is

used.


Imp Guide

431-DV OTHER PAYER AMOUNT PAID RW Imp Guide: Required if other

payer has approved payment

for some/all of the billing.

Not used for patient financial

responsibility only billing.

Not used for non-governmental

agency programs if Other


Amount (352-NQ) is

submitted.


Imp Guide

Workers’ Compensation Segment Questions Check Claim Billing/Claim Rebill




14


This Segment is situational x

DUR/PPS Segment Questions Check Claim Billing/Claim Rebill




DUR/PPS Segment


= ―Ø8‖



Usage

Payer Situation

473-7E DUR/PPS CODE COUNTER Maximum of 9

occurrences.


DUR/PPS Segment is used.


Imp Guide

Joel.jonas-

1000

REASON FOR SERVICE CODE RW Imp Guide: Required if this


coverage, pricing, patient

financial responsibility, and/or

drug utilization review

outcome.

Required if this field affects

payment for or documentation

of professional pharmacy

service.


Imp Guide

44Ø-E5 PROFESSIONAL SERVICE CODE RW Imp Guide: Required if this





outcome.




service.


Imp Guide

441-E6 RESULT OF SERVICE CODE RW Imp Guide: Required if this





outcome.


15


DUR/PPS Segment


= ―Ø8‖



Usage

Payer Situation




service.


Imp Guide

474-8E DUR/PPS LEVEL OF EFFORT RW Imp Guide: Required if this





outcome.




service.


Imp Guide

475-J9 DUR CO-AGENT ID QUALIFIER 03 = NDC RW Imp Guide: Required if DUR

Co-Agent ID (476-H6) is used.


Imp Guide

476-H6 DUR CO-AGENT ID NDC RW Imp Guide: Required if this





outcome.




service.


Imp Guide

Coupon Segment Questions Check Claim Billing/Claim Rebill



This Segment is situational X Not required at this time, fields intentionally not listed.


16


Compound Segment Questions Check Claim Billing/Claim Rebill




Compound Segment


= ―1Ø‖



Usage

Payer Situation

45Ø-EF Compound Dosage Form

Description Code

M

451-EG Compound Dispensing Unit Form

Indicator

M

447-EC Compound Ingredient Component

Count

Maximum 25

ingredients

M

488-RE Compound Product ID Qualifier M

489-TE Compound Product ID M

448-ED Compound Ingredient Quantity M

449-EE COMPOUND INGREDIENT DRUG

COST


for receiver claim

determination when multiple

products are billed.


Imp Guide

49Ø-UE COMPOUND INGREDIENT BASIS

OF COST DETERMINATION


for receiver claim

determination when multiple

products are billed.


Imp Guide

362-2G COMPOUND INGREDIENT

MODIFIER CODE COUNT

Maximum count of 1Ø. RW Imp Guide: Required when

Compound Ingredient Modifier

Code (363-2H) is sent.


Imp Guide

363-2H COMPOUND INGREDIENT

MODIFIER CODE


necessary for


agency programs.


Imp Guide

Clinical Segment Questions Check Claim Billing/Claim Rebill



17





18


Clinical Segment


= ―13‖



Usage

Payer Situation

491-VE DIAGNOSIS CODE COUNT Maximum count of 5. RW Imp Guide: Required if

Diagnosis Code Qualifier (492-

WE) and Diagnosis Code (424-

DO) are used.


Imp Guide

492-WE DIAGNOSIS CODE QUALIFIER 01 = ICD-9 RW Imp Guide: Required if

Diagnosis Code (424-DO) is

used.


Imp Guide

424-DO DIAGNOSIS CODE See Pharmacy Billing

Manual

RW Imp Guide: Required if this field

could result in different




outcome.


payment for professional

pharmacy service.

Required if this information can

be used in place of prior

authorization.



agency programs.


Imp Guide

Additional Documentation Segment Questions Check Claim Billing/Claim Rebill



This Segment is situational X Not required at this time, intentionally not listed

Facility Segment Questions Check Claim Billing/Claim Rebill



This Segment is situational X Not required at this time, intentionally not listed


19


Narrative Segment Questions Check Claim Billing/Claim Rebill



This Segment is situational X Not required at this time, intentionally not listed.

RESPONSE CLAIM BILLING/CLAIM REBILL PAYER SHEET

GENERAL INFORMATION



Checkup


Claim Billing/Claim Rebill PAID (or Duplicate of PAID) Response

The following lists the segments and fields in a Claim Billing or Claim Rebill response (Paid or Duplicate of

Paid) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.

Response Transaction Header Segment

Questions


Accepted/Paid (or Duplicate of Paid)



Response Transaction Header

Segment

Claim Billing/Claim Rebill –

Accepted/Paid (or Duplicate

of Paid)


Usage

Payer Situation

1Ø2-A2 Version/Release Number DØ M

1Ø3-A3 Transaction Code B1, B3 M

1Ø9-A9 Transaction Count Same value as in

request

M

5Ø1-F1 Header Response Status A = Accepted M

2Ø2-B2 Service Provider ID Qualifier Same value as in

request

M

2Ø1-B1 Service Provider ID Same value as in

request

M

4Ø1-D1 Date of Service Same value as in

request

M

Response Message Segment Questions Check Claim Billing/Claim Rebill






20


Response Message Segment


= ―2Ø‖



of Paid)


Usage

Payer Situation

5Ø4-F4 Message 20 = Response Message

Segment

Imp Guide: Required if text is

needed for clarification or

detail.


Imp Guide

Response Insurance Segment Questions Check Claim Billing/Claim Rebill




This Segment is situational X Field Not required at this time, intentionally removed.

Response Patient Segment Questions Check Claim Billing/Claim Rebill





Response Patient Segment


= ―29‖



of Paid)


Usage

Payer Situation

31Ø-CA PATIENT FIRST NAME RW Imp Guide: Required if

known.


Imp Guide

311-CB PATIENT LAST NAME RW Imp Guide: Required if

known.


Imp Guide

3Ø4-C4 DATE OF BIRTH RW Imp Guide: Required if

known.


Imp Guide


21


Response Status Segment Questions Check Claim Billing/Claim Rebill




Response Status Segment


= ―21‖



of Paid)


Usage

Payer Situation

112-AN Transaction Response Status P=Paid

D=Duplicate of Paid

M

5Ø3-F3 AUTHORIZATION NUMBER RW Imp Guide: Required if

needed to identify the

transaction.


Imp Guide

547-5F APPROVED MESSAGE CODE

COUNT

Maximum count of 5. RW Imp Guide: Required if

Approved Message Code

(548-6F) is used.


Imp Guide

548-6F APPROVED MESSAGE CODE RW Imp Guide: Required if

Approved Message Code

Count (547-5F) is used and

the sender needs to

communicate additional

follow up for a potential

opportunity.


Imp Guide

13Ø-UF ADDITIONAL MESSAGE

INFORMATION COUNT



Additional Message

Information (526-FQ) is

used.


Imp Guide

132-UH ADDITIONAL MESSAGE

INFORMATION QUALIFIER


Additional Message


used.


Imp Guide


22




= ―21‖



of Paid)


Usage

Payer Situation

526-FQ ADDITIONAL MESSAGE

INFORMATION

RW Imp Guide: Required when

additional text is needed for

clarification or detail.


Imp Guide

131-UG ADDITIONAL MESSAGE

INFORMATION CONTINUITY

RW Imp Guide: Required if and

only if current repetition of

Additional Message


used, another populated

repetition of Additional

Message Information (526-

FQ) follows it, and the text of

the following message is a

continuation of the current.


Imp Guide

549-7F HELP DESK PHONE NUMBER

QUALIFIER

RW Imp Guide: Required if Help

Desk Phone Number (55Ø-

8F) is used.


Imp Guide

55Ø-8F HELP DESK PHONE NUMBER


needed to provide a support

telephone number to the

receiver.


Imp Guide

Response Claim Segment Questions Check Claim Billing/Claim Rebill





23


Response Claim Segment


= ―22‖



of Paid)


Usage

Payer Situation

455-EM Prescription/Service Reference

Number Qualifier

1 = RxBilling M Imp Guide: For Transaction

Code of B1, in the Response

Claim Segment, the





Number

M

Response Pricing Segment Questions Check Claim Billing/Claim Rebill




Response Pricing Segment


= ―23‖



of Paid)


Usage

Payer Situation

5Ø5-F5 PATIENT PAY AMOUNT R

5Ø6-F6 INGREDIENT COST PAID R

5Ø7-F7 DISPENSING FEE PAID R Imp Guide: Required if this

value is used to arrive at the

final reimbursement.


Imp Guide

521-FL INCENTIVE AMOUNT PAID RW Imp Guide: Required if this



Required if Incentive Amount

Submitted (438-E3) is

greater than zero (Ø).


Imp Guide

563-J2 OTHER AMOUNT PAID COUNT Maximum count of 3. RW Imp Guide: Required if

Other Amount Paid (565-J4)

is used.


Imp Guide


24




= ―23‖



of Paid)


Usage

Payer Situation

564-J3 OTHER AMOUNT PAID

QUALIFIER


Other Amount Paid (565-J4)

is used.


Imp Guide

565-J4 OTHER AMOUNT PAID RW Imp Guide: Required if this



Required if Other Amount

Claimed Submitted (48Ø-

H9) is greater than zero (Ø).


Imp Guide

566-J5 OTHER PAYER AMOUNT

RECOGNIZED




Required if Other Payer

Amount Paid (431-DV) is

greater than zero (Ø) and

Coordination of

Benefits/Other Payments

Segment is supported.


Imp Guide

5Ø9-F9 TOTAL AMOUNT PAID R

522-FM BASIS OF REIMBURSEMENT

DETERMINATION


Ingredient Cost Paid (5Ø6-

F6) is greater than zero (Ø).

Required if Basis of Cost

Determination (432-DN) is

submitted on billing.


Imp Guide


25




= ―23‖



of Paid)


Usage

Payer Situation

346-HH BASIS OF CALCULATION—

DISPENSING FEE


Dispensing Status (343-HD)

on submission is P (Partial

Fill) or C (Completion of

Partial Fill).


Imp Guide

347-HJ BASIS OF CALCULATION—

COPAY


Dispensing Status (343-HD)

on submission is P (Partial

Fill) or C (Completion of

Partial Fill).


Imp Guide

Response DUR/PPS Segment Questions Check Claim Billing/Claim Rebill





Response DUR/PPS Segment


= ―24‖



of Paid)


Usage

Payer Situation

567-J6 DUR/PPS RESPONSE CODE

COUNTER

Maximum 9

occurrences supported.


Reason For Service Code

(439-E4) is used.


Imp Guide

439-E4 REASON FOR SERVICE CODE RW Imp Guide: Required if

utilization conflict is detected.


Imp Guide


26




= ―24‖



of Paid)


Usage

Payer Situation

528-FS CLINICAL SIGNIFICANCE CODE Blank = Not specified

1 = Major

2 = Moderate

3 = Minor

9 = Undetermined


needed to supply additional

information for the utilization

conflict.


Imp Guide

529-FT OTHER PHARMACY INDICATOR 0 = Not specified

1 = Your pharmacy

2 = Other pharmacy in

same chain

3 = Other pharmacy




conflict.


Imp Guide

53Ø-FU PREVIOUS DATE OF FILL RW Imp Guide: Required if



conflict.

Required if Quantity of

Previous Fill (531-FV) is used.


Imp Guide

531-FV QUANTITY OF PREVIOUS FILL RW Imp Guide: Required if



conflict.

Required if Previous Date Of

Fill (53Ø-FU) is used.


Imp Guide

532-FW DATABASE INDICATOR RW Imp Guide: Required if



conflict.


Imp Guide


27




= ―24‖



of Paid)


Usage

Payer Situation

533-FX OTHER PRESCRIBER INDICATOR 0 = Not specified

1 = Same prescriber

2 = Other prescriber




conflict.


Imp Guide

544-FY DUR FREE TEXT MESSAGE RW Imp Guide: Required if



conflict.


Imp Guide

57Ø-NS DUR ADDITIONAL TEXT RW Imp Guide: Required if



conflict.


Imp Guide

Response Coordination of Benefits/Other

Payers Segment Questions






Response Coordination of

Benefits/Other Payers Segment


= ―28‖



of Paid)


Usage

Payer Situation

355-NT OTHER PAYER ID COUNT Maximum count of 3. M

338-5C OTHER PAYER COVERAGE TYPE M

339-6C OTHER PAYER ID QUALIFIER RW Imp Guide: Required if Other



Imp Guide


28





= ―28‖



of Paid)


Usage

Payer Situation

34Ø-7C OTHER PAYER ID RW Imp Guide: Required if other

insurance information is

available for coordination of

benefits.


Imp Guide

991-MH OTHER PAYER PROCESSOR

CONTROL NUMBER

RW Imp Guide: Required if other



benefits.


Imp Guide

356-NU OTHER PAYER CARDHOLDER ID RW Imp Guide: Required if other



benefits.


Imp Guide

992-MJ OTHER PAYER GROUP ID RW Imp Guide: Required if other



benefits.


Imp Guide

142-UV OTHER PAYER PERSON CODE RW Imp Guide: Required if

needed to uniquely identify

the family members within the

Cardholder ID, as assigned

by the other payer.


Imp Guide

127-UB Other Payer Help Desk Phone

Number



telephone number of the

other payer to the receiver.


Imp Guide


29





= ―28‖



of Paid)


Usage

Payer Situation

143-

UW

OTHER PAYER PATIENT

RELATIONSHIP CODE



the relationship of the patient

to the cardholder ID, as

assigned by the other payer.


Imp Guide

144-UX OTHER PAYER Benefit Effective

Date


other coverage is known

which is after the Date of

Service submitted.


Imp Guide

145-UY OTHER PAYER Benefit

Termination Date




Service submitted.


Imp Guide

CLAIM BILLING/CLAIM REBILL ACCEPTED/REJECTED RESPONSE

Claim Billing/Claim Rebill accepted/rejected Response


Questions

Check Claim Billing/Claim Rebill Accepted/Rejected




Segment


Accepted/Rejected


Usage

Payer Situation




request

M



request

M


request

M


30



Segment


Accepted/Rejected


Usage

Payer Situation


request

M

Response Message Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected






= ―2Ø‖


Accepted/Rejected


Usage

Payer Situation

5Ø4-F4 MESSAGE RW Imp Guide: Required if text

is needed for clarification or

detail.


Imp Guide

Response Insurance Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected



This Segment is situational X Fields not required at this time

Response Patient Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected






= ―29‖


Accepted/Rejected


Usage

Payer Situation

31Ø-CA PATIENT FIRST NAME RW Imp Guide: Required if

known.


Imp Guide


31




= ―29‖


Accepted/Rejected


Usage

Payer Situation

311-CB PATIENT LAST NAME RW Imp Guide: Required if

known.


Imp Guide

3Ø4-C4 DATE OF BIRTH RW Imp Guide: Required if

known.


Imp Guide

Response Status Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected





= ―21‖


Accepted/Rejected


Usage

Payer Situation

112-AN TRANSACTION RESPONSE

STATUS

R = Reject M

5Ø3-F3 AUTHORIZATION NUMBER R Imp Guide: Required if


transaction.


Imp Guide

51Ø-FA REJECT COUNT Maximum count of 5. R

511-FB REJECT CODE R

546-4F REJECT FIELD OCCURRENCE

INDICATOR

RW Imp Guide: Required if a

repeating field is in error, to

identify repeating field

occurrence.


Imp Guide


INFORMATION COUNT



Additional Message


used.


Imp Guide


32




= ―21‖


Accepted/Rejected


Usage

Payer Situation




Additional Message


used.


Imp Guide


INFORMATION





Imp Guide


QUALIFIER



8F) is used.


Imp Guide

55Ø-8F HELP DESK PHONE NUMBER RW Imp Guide: Required if



receiver.


Imp Guide

Response Claim Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected





= ―22‖


Accepted/Rejected


Usage

Payer Situation

455-EM PRESCRIPTION/SERVICE

REFERENCE NUMBER QUALIFIER



Claim Segment, the




4Ø2-D2 PRESCRIPTION/SERVICE

REFERENCE NUMBER

M


33


Response DUR/PPS Segment Questions Check Claim Billing/Claim Rebill Accepted/Rejected






= ―24‖


Accepted/Rejected


Usage

Payer Situation

567-J6 DUR/PPS RESPONSE CODE

COUNTER

Maximum 9 occurrences

supported.


Reason For Service Code

(439-E4) is used.


Imp Guide

439-E4 REASON FOR SERVICE CODE RW Imp Guide: Required if

utilization conflict is

detected.


Imp Guide

528-FS CLINICAL SIGNIFICANCE CODE RW Imp Guide: Required if



conflict.


Imp Guide

529-FT OTHER PHARMACY INDICATOR RW Imp Guide: Required if



conflict.


Imp Guide

53Ø-FU PREVIOUS DATE OF FILL RW Imp Guide: Required if



conflict.

Required if Quantity of

Previous Fill (531-FV) is

used.


Imp Guide


34




= ―24‖


Accepted/Rejected


Usage

Payer Situation

531-FV QUANTITY OF PREVIOUS FILL RW Imp Guide: Required if



conflict.

Required if Previous Date Of

Fill (53Ø-FU) is used.


Imp Guide

532-FW DATABASE INDICATOR RW Imp Guide: Required if



conflict.


Imp Guide

533-FX OTHER PRESCRIBER INDICATOR RW Imp Guide: Required if



conflict.


Imp Guide

544-FY DUR FREE TEXT MESSAGE RW Imp Guide: Required if



conflict.


Imp Guide

57Ø-NS DUR ADDITIONAL TEXT RW Imp Guide: Required if



conflict.


Imp Guide

Response Prior Authorization Segment

Questions






35


Response Prior Authorization

Segment


= ―26‖


Accepted/Rejected


Usage

Payer Situation

498-PY PRIOR AUTHORIZATION

NUMBER–ASSIGNED


the receiver must submit this

Prior Authorization Number

in order to receive payment

for the claim.


Imp Guide

Response Coordination of Benefits/Other

Payers Segment Questions








= ―28‖


Accepted/Rejected


Usage

Payer Situation

355-NT OTHER PAYER ID COUNT Maximum count of 3. M

338-5C OTHER PAYER COVERAGE TYPE M

339-6C OTHER PAYER ID QUALIFIER RW Imp Guide: Required if Other



Imp Guide

34Ø-7C OTHER PAYER ID RW Imp Guide: Required if other



benefits.


Imp Guide

991-MH OTHER PAYER PROCESSOR

CONTROL NUMBER

RW Imp Guide: Required if other



benefits.


Imp Guide


36





= ―28‖


Accepted/Rejected


Usage

Payer Situation

356-NU OTHER PAYER CARDHOLDER ID RW Imp Guide: Required if other



benefits.


Imp Guide

992-MJ OTHER PAYER GROUP ID RW Imp Guide: Required if other



benefits.


Imp Guide

142-UV OTHER PAYER PERSON CODE RW Imp Guide: Required if


the family members within the

Cardholder ID, as assigned

by the other payer.


Imp Guide

127-UB Other Payer Help Desk Phone

Number



telephone number of the

other payer to the receiver.


Imp Guide

143-

UW

OTHER PAYER PATIENT

RELATIONSHIP CODE



the relationship of the patient

to the cardholder ID, as

assigned by the other payer.


Imp Guide

144-UX OTHER PAYER Benefit Effective

Date




Service submitted.


Imp Guide


37





= ―28‖


Accepted/Rejected


Usage

Payer Situation

145-UY OTHER PAYER Benefit

Termination Date




Service submitted.


Imp Guide

CLAIM BILLING/CLAIM REBILL REJECTED/REJECTED RESPONSE

Claim Billing/Claim Rebill Rejected/Rejected Response


Questions

Check Claim Billing/Claim Rebill Rejected/Rejected




Segment


Rejected/Rejected


Usage

Payer Situation




request

M

5Ø1-F1 Header Response Status R = Rejected M


request

M


request

M


request

M

Response Message Segment Questions Check Claim Billing/Claim Rebill Rejected/Rejected





38




= ―2Ø‖


Rejected/Rejected


Usage

Payer Situation

5Ø4-F4 MESSAGE RW Imp Guide: Required if text

is needed for clarification or

detail.


Imp Guide

Response Status Segment Questions Check Claim Billing/Claim Rebill Rejected/Rejected





= ―21‖


Rejected/Rejected


Usage

Payer Situation


STATUS

R = Reject M

5Ø3-F3 AUTHORIZATION NUMBER RW Imp Guide: Required if


transaction.


Imp Guide




INDICATOR




occurrence.


Imp Guide


INFORMATION COUNT



Additional Message


used.


Imp Guide


39




= ―21‖


Rejected/Rejected


Usage

Payer Situation




Additional Message


used.


Imp Guide


INFORMATION





Imp Guide


QUALIFIER



8F) is used.


Imp Guide




receiver.


Imp Guide

NCPDP VERSION D CLAIM REVERSAL (B2 TRANSACTION)

GENERAL INFORMATION



Checkup


Field legend for columns

Payer Usage

Column

Value Explanation Payer

Situation

Column

MANDATORY M The Field is mandatory for the Segment in the

designated Transaction.

No

Required R The Field has been designated with the situation of

―Required‖ for the Segment in the designated

Transaction.

No


40


Payer Usage

Column

Value Explanation Payer

Situation

Column

Qualified Requirement RW ―Required when‖. The situations designated have

qualifications for usage (―Required if x‖, ―Not

required if y‖).

Yes

NOT USED NA The Field is not used for the Segment in the

designated Transaction.

Not used are shaded for clarity for the Payer when

creating the Template. For the actual Payer

Template, not used fields must be deleted from the

transaction (the row in the table removed).

No

Question Answer

What is your reversal window? (If transaction is billed today what is the timeframe for

reversal to be submitted?)

180 Days

Claim Reversal Transaction

The following lists the segments and fields in a Claim Reversal Transaction for the NCPDP Telecommunication

Standard Implementation Guide Version D.Ø.

Transaction Header Segment Questions Check Claim Reversal



Source of certification IDs required in

Software Vendor/Certification ID (11Ø-AK) is

Payer Issued

X



Switch/VAN issued



Not used

Transaction Header Segment Claim Reversal


Usage

Payer Situation

1Ø1-A1 BIN Number If more than one

BIN/PCN but all plans

use the same segments

and fields and

situations, enter

multiple BIN/PCNs

under General

Information above.

M


1Ø3-A3 Transaction Code B2 M

1Ø4-A4 Processor Control Number NVM M

1Ø9-A9 Transaction Count Up to 4 transactions. M


41


Transaction Header Segment Claim Reversal


Usage

Payer Situation

2Ø2-B2 Service Provider ID Qualifier 01 = National Provider

Number (NPI)

M

2Ø1-B1 Service Provider ID NPI M

4ø1-d1 Date of Service CCYYMMDD M

11Ø-AK Software Vendor/Certification ID Assigned with vendor is

certified, will reject if

missing or not valid

M

Insurance Segment Questions Check Claim Reversal



This Segment is situational X Not Used at this time – Intentionally omitted

Claim Segment Questions Check Claim Reversal



Claim Segment


= ―Ø7‖

Claim Reversal


Usage

Payer Situation


Number Qualifier

M Imp Guide: For Transaction

Code of B2, in the Claim

Segment, the



(455-EM) is 1 (RX Billing).


Number

M

436-E1 Product/Service ID Qualifier 03 = NDC M

4Ø7-D7 Product/Service ID NDC M

4Ø3-D3 FILL NUMBER RW Imp Guide: Required if needed

for reversals when multiple fills

of the same

Prescription/Service Reference

Number (4Ø2-D2) occur on

the same day.


Imp Guide


42


Claim Segment


= ―Ø7‖

Claim Reversal


Usage

Payer Situation

3Ø8-C8 OTHER COVERAGE CODE 00 = Not specified

01 = No other coverage

02 = Other coverage

exists – payment collected

03 = Other coverage

exists – claim not covered

04 = Other coverage

exists – payment not

collected

05 = Managed care plan

denial

06 = Other coverage

denied – not a

participating provider

07 = Other coverage

exists – not in effect on

DOS

08 = Claim is billing for

copay


by receiver to match the claim

that is being reversed.


Imp Guide

Pricing Segment Questions Check Claim Reversal




Pricing Segment


= ―11‖

Claim Reversal


Usage

Payer Situation

438-E3 INCENTIVE AMOUNT SUBMITTED RW Imp Guide: Required if this

field could result in

contractually agreed upon

payment.


Imp Guide

43Ø-DU GROSS AMOUNT DUE R Imp Guide: Required if this

field could result in


payment.


Imp Guide


43


Coordination of Benefits/Other Payments

Segment Questions

Check Claim Reversal





Payments Segment


= ―Ø5‖

Claim Reversal


Usage

Payer Situation

337-4C Coordination of Benefits/Other

Payments Count

Maximum count of 9. M

338-5C Other Payer Coverage Type M

DUR/PPS Segment Questions Check Claim Reversal



This Segment is situational X Segment not used at this time – Intentionally Omitted

RESPONSE CLAIM REVERSAL PAYER SHEET

General Information


Plan Name/Group Name: Nevada

Medicaid/Nevada Checkup


Claim Reversal accepted/Approved Response

The following lists the segments and fields in a Claim Reversal response (Approved) Transaction for the NCPDP:

Telecommunication Standard Implementation Guide Version D.Ø.


Questions

Check Claim Reversal – Accepted/Approved




Segment

Claim Reversal –

Accepted/Approved


Usage

Payer Situation




request

M



request

M


request

M


44



Segment

Claim Reversal –

Accepted/Approved


Usage

Payer Situation


request

M

Response Message Segment Questions Check Claim Reversal – Accepted/Approved






= ―2Ø‖

Claim Reversal –

Accepted/Approved


Usage

Payer Situation

5Ø4-F4 Message RW Imp Guide: Required if text is


detail.


Imp Guide

Response Status Segment Questions Check Claim Reversal – Accepted/Approved





= ―21‖

Claim Reversal –

Accepted/Approved


Usage

Payer Situation

112-AN Transaction Response Status A = Approved M

5Ø3-F3 AUTHORIZATION NUMBER R Imp Guide: Required if


transaction.


Imp Guide

Response Claim Segment Questions Check Claim Reversal – Accepted/Approved




45




= ―22‖

Claim Reversal –

Accepted/Approved


Usage

Payer Situation


Number Qualifier



Claim Segment, the





Number

M

Response Pricing Segment Questions Check Claim Reversal – Accepted/Approved






= ―23‖

Claim Reversal –

Accepted/Approved


Usage

Payer Situation

521-FL INCENTIVE AMOUNT PAID RW Imp Guide: Required if this

field is reporting a


payment.


Imp Guide

5Ø9-F9 TOTAL AMOUNT PAID R Imp Guide: Required if any

other payment fields sent by

the sender.


Imp Guide

CLAIM REVERSAL ACCEPTED/REJECTED RESPONSE

Claim reversal accepted/rejected Response


Questions

Check Claim Reversal - Accepted/Rejected




46



Segment

Claim Reversal –

Accepted/Rejected


Usage

Payer Situation



1Ø9-A9 Transaction Count Same value as in request M


2Ø2-B2 Service Provider ID Qualifier Same value as in request M

2Ø1-B1 Service Provider ID Same value as in request M

4Ø1-D1 Date of Service Same value as in request M

Response Message Segment Questions Check Claim Reversal - Accepted/Rejected






= ―2Ø‖

Claim Reversal –

Accepted/Rejected


Usage

Payer Situation

5Ø4-F4 MESSAGE R Imp Guide: Required if text is


detail.


Imp Guide

Response Status Segment Questions Check Claim Reversal - Accepted/Rejected





= ―21‖

Claim Reversal –

Accepted/Rejected


Usage

Payer Situation


STATUS

R = Reject M

5Ø3-F3 AUTHORIZATION NUMBER R




47




= ―21‖

Claim Reversal –

Accepted/Rejected


Usage

Payer Situation


INDICATOR




occurrence.


Imp Guide


INFORMATION COUNT



Additional Message

Information (526-FQ) is used.


Imp Guide




Additional Message

Information (526-FQ) is used.


Imp Guide


INFORMATION





Imp Guide


QUALIFIER



8F) is used.


Imp Guide




receiver.


Imp Guide

Response Claim Segment Questions Check Claim Reversal - Accepted/Rejected




48




= ―22‖

Claim Reversal –

Accepted/Rejected


Usage

Payer Situation

455-EM PRESCRIPTION/SERVICE

REFERENCE NUMBER QUALIFIER



Claim Segment, the




4Ø2-D2 PRESCRIPTION/SERVICE

REFERENCE NUMBER

M

CLAIM REVERSAL REJECTED/REJECTED RESPONSE

Claim Reversal Rejected/Rejected Response


Questions

Check Claim Reversal - Rejected/Rejected




Segment

Claim Reversal –

Rejected/Rejected


Usage

Payer Situation



1Ø9-A9 Transaction Count Same value as in request M


2Ø2-B2 Service Provider ID Qualifier Same value as in request M

2Ø1-B1 Service Provider ID Same value as in request M

4Ø1-D1 Date of Service Same value as in request M

Response Message Segment Questions Check Claim Reversal – Rejected/Rejected





49




= ―2Ø‖

Claim Reversal –

Rejected/Rejected


Usage

Payer Situation

5Ø4-F4 MESSAGE R Imp Guide: Required if text is


detail.


Imp Guide

Response Status Segment Questions Check Claim Reversal - Rejected/Rejected





= ―21‖

Claim Reversal –

Rejected/Rejected


Usage

Payer Situation


STATUS

R = Reject M

5Ø3-F3 AUTHORIZATION NUMBER R




INDICATOR




occurrence.


Imp Guide


QUALIFIER



8F) is used.


Imp Guide




receiver.


Imp Guide


50


Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP

Published 10/26/2011

nevada medicaid and nevada checkup ncpdp d.0 payer sheet ... · 1Ø1-a1 bin number 001553 m 1Ø2-a2...

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